Brain donor forms

We encourage anyone that is interested in becoming a brain tissue donor to complete this form for themselves and their families. By registering as a brain tissue donor with the BEARS® Tissue Program, you are declaring your intent to donate brain tissue as well as formally making your wishes known to your family or caregiver before the time comes. The BEARS® brain donor registration form has to be submitted anytime before an actual brain tissue donation event occurs.

Completion of the consent form will give us authorization to carry out the brain tissue donation » process and allow BEARS® staff to retrieve the donor’s health information for research purposes. Since this is the first form that needs to be completed before any arrangements can be made to initiate the donation process, it would be helpful to send it to us as soon as possible, preferably within 24 hours from the time the donor passes away. Since brain tissue is extremely fragile and degrades quickly, it is critical for the tissue recovery and transport process to occur within this 24-hour time frame. As more time passes between death and adequate preparation of brain tissue, fewer and fewer types of research studies are possible with the donated tissue.

Instructions:Completion and submission of the BEARS® brain donor consent form (PDF) » needs to occur as soon as possible after you express interest and decide to donate brain tissue. The form can be faxed to us at 916-703-0483 or e-mailed to: mindbears@ucdavis.edu. (You can directly type out your information on the fields provided on the PDF document, save, and then e-mail the form to us.)

Completion of this questionnaire will help researchers obtain a complete and accurate profile of the donor’s personal and medical background for research purposes. The questionnaire can be filled out after the donation process, but preferably within the first two months after the initial brain donation call.

If you cannot access the online version, you can choose to complete the PDF version of the BEARS® brain donor questionnaire (PDF). » Once completed, the form can be faxed to us at 916-703-0483 or e-mailed to: mindbears@ucdavis.edu. (You can directly type out your information on the fields provided on the PDF document, save, and then e-mail the form to us.)

If you need additional help in completing the questionnaire, you also have the option of completing the form when you meet with our clinical social worker during the scheduled follow-up visit. The clinical social worker can assist you in filling out any component of the questionnaire that you do not understand, and will collect the form from you at the end of the follow-up visit.